Marcia Angell’s recently published two-part series on psychiatry in the New York Review of Books (“The Epidemic of Mental Illness: Why” http://www.nyrb.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/and “The Truth about the Drug Companies” http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry ) is a serious indictment of contemporary psychiatry.Although, not every statement Angell makes nor every conclusion she draws about the field is entirely accurate, the essays contain more wheat than chaff, which doesn’t speak well for the sad state of psychiatry.
In reviewing three books (Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch; Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker; and Unhinged: The Trouble with Psychiatry – A Doctor’s Revelations about a Profession in Crisis by Daniel Carlat), Angell’s first essay highlights the dramatic changes in the apparent prevalence of psychiatric disorders as evidenced by increasing psychiatric disability claims, number of individuals in psychiatric treatment (sharply up for children), and psychiatric medication sales.All of this data, although – in part - alarming, is relatively straightforward and undeniable. I vehemently share her concern about the rise in individuals receiving disability for treatable mood disorders.I would add that disability payments can then make certain co-occurring illnesses (such as substance use disorders) more difficult to treat, creating even more disability.Angell’s discussion of the relationship between the pharmaceutical industry and the FDA vis a vis the outcomes of randomized controlled efficacy trials (RCTs) contains some truths, but I do not conclude, as she does, that these trials demonstrate that antidepressants are no better than placebo for the treatment of depression.The complexities of psychiatric RCT design, especially regarding inherent problems with diagnostic criteria (which she addresses, in a different context in the second essay), make me doubt that these medications have no efficacy for certain patients carefully diagnosed by a clinician as moderately or severely depressed.Angell does a great job, however, discussing the role of the placebo effect in trials and – in general – I agree with and applaud the essay’s questioning, skeptical tone regarding the “epidemic” of psychiatric disability and medication sales/treatment.
In her second essay, Angell adds another book to her review, the disturbingly influential Diagnostic and Statistical Manual (DSM).She takes on this “bible” of psychiatry, which she clearly sees is cozily cradled by the arms of Big Pharma.Her understanding of the origin of the DSM (designed to ensure reliability in psychiatric research) and its major weaknesses (its lack of empirical validity and intentionally atheoretical approach met to sidestep the internecine war within psychiatry) is sharp and insightful.And Angell recognizes the impact on individuals and society of such a scientifically and intellectually flabby checklist-approach to psychiatric diagnosis.
To those of us who trained in psychiatry at Johns Hopkins, Angell’s critique of the field is all too familiar.Since the launch of DSM-III in the 1980s, the psychiatry department at Hopkins has consistently and publicly challenged the DSM’s categorical approach to patient formulation.We have witnessed the harmful effects of the ascendancy of the DSM on our field, including the creation of a generation of psychiatrists who no longer routinely conduct a thorough psychiatric evaluation for each patient.It’s now a rare psychiatrist who takes stock of an individual’s life story, intelligence, temperament, and behaviors before reducing the origin of the patient’s complaint to brain disease.
By contrast, at Hopkins we have remained committed to a measured, systematic approach to the psychiatric evaluation of each and every patient.Although we recognize the time-consuming nature of such an evaluation, we also know that it’s essential to the practice of psychiatry.Only by taking a thorough history and performing a complete mental status examination on every patient is a psychiatrist able to understand each patient as an individual.And only by understanding the whole patient, can a clinician develop a comprehensive and personalized treatment plan. This systematic and robust approach, based on The Perspectives of Psychiatry by McHugh and Slavney, allows the clinician to transcend the criteria-based nature of the DSM.The Perspectives approach ensures the consideration of many possible biological and psychological origins of a patient’s distress.
Although DSM-V is on the horizon, critics like Angell are giving voice to concerns shared by many, including those of us at Hopkins, about the state of psychiatry.We encourage such public conversation to continue as there is a clear need for questioning the state of contemporary psychiatry.I hope that other psychiatrists will join us as we continue to advocate for a more personalized and systematic diagnosis and treatment approach for all patients.
Margaret S. Chisolm, MD
Department of Psychiatry and Behavioral Sciences
Johns Hopkins University School of Medicine